and impotent). A high number of the relatives of
those with chronic pain also suffer sadness and
anxiety and withdraw from social activities
Effects on health care systems
Pain accounts for considerable expenditure and
consumption of resources in primary care. 27,28 In
a study by Breivik et al,1 60% of chronic pain
patients reported that they had visited their
clinician 2–9 times in the months before the study
commenced and that 11% had visited at least ten
times. A total of 70% visited their GP, whereas only
2% were treated by pain specialist.
People who leave their employment or lose their
job as a result of pain, and those who perceive their
pain affects their family, are those who use the
healthcare systems the most. 21 It has also been
shown that pain is often adequately diagnosed and
treated in primary care, resulting in excessive
appointments and overuse of healthcare resources. 21
Based on the definition of disease, most chronic pain
can be considered as a disease in its own right. The
new ICD-11 classification acknowledges that chronic
pain is a disease in its own right by introducing the
coding of ‘chronic primary pain’. Yet, at the same
time many patients with ‘secondary chronic pain’
have emotional distress and important interference
with daily activities and social participation.
As such, they fit into the concept of pain as a disease
while their pain can be a symptom of an underlying
Chronification should be considered as
a continuum where initially, pain could be
a symptom, but can develop into a disease. Therefore,
disease-specific treatment paradigms, focusing on
multimodal strategies, need to be applied, which
might differ from those were chronic pain is merely
a symptom of an underlying chronic condition.
Because of the high prevalence of chronic pain
and the resultant serious medical and non-medical
consequences, effective health care policies,
acknowledging pain as a public health priority, and
multidisciplinary treatment strategies to prevent
and manage pain and minimise the disability that
it causes, are required.
In a study comparing health-related quality of life
(HRQoL) in patients with acute pain and chronic
pain with those without pain, chronic pain patients
received the worst score in all dimensions of
Effect on work
Studies have demonstrated that that absenteeism,
presenteeism and early retirement related to chronic
pain present a significant burden as least as great as
conditions that are typically prioritised as public
health concerns. 25 In the 45–65-year-old age group,
low back pain is one of the most frequently cited
medical reasons for loss of work. 26
Effect on social relationships and family
Chronic pain can restrict a person’s leisure activities
and social interactions. Family members often find
that they need to undertake care duties and must
become involved in decision making regarding
medical treatment and consequently suffer negative
feelings (including feeling overburdened, frustrated
1 Breivik H et al. Survey
of chronic pain in Europe:
prevalence, impact on daily
life, and treatment. Eur J Pain
2 IASP Task Force on Taxonomy
(eds Merskey H, Bogduk N).
Classification of Chronic Pain,
Second Edition. IASP Press,
3 International Association for
the Study of Pain (IASP). IASP’s
proposed definition of pain
released for comment. www.
(accessed October 2019).
4 Williams AC, Craig KD.
Updating the definition of pain.
5 Kosek E et al. Do we need a
third mechanistic descriptor
for chronic pain states? Pain
6 IASP. Classification of chronic
pain. Descriptions of chronic
pain syndromes and definitions
of pain terms. Prepared by the
International Association for the
Study of Pain, Subcommittee on
Taxonomy. Pain Suppl 1986;3:S1–
7 Treede RD et al. A classification
of chronic pain for ICD-11. Pain
8 ICD. MG30. Chronic pain.
76053 (accessed October 2019).
9 IASP. IASP terminology. www.
lsensitization (accessed October
10 Morlion B et al. Pain
chronification: what should a
non-pain medicine specialist
know? CMRO 2018;34:1169–78.
11 Raffaeli W, Arnaudo E. Pain
as a disease: an overview. J Pain
12 IASP/EFIC. IASP now
recommends the global adoption
of EFIC’s Declaration on Chronic
Pain as a Major Heathcare
Problem, a Disease in its own
13 World Health Organization.
Preamble to the Constitution of
the World Health Organization.
WHO, New York, USA;1946.
14 Tracey I, Bushell MC. How
neuroimaging studies have
challenged us to rethink: is
chronic pain a disease? J
15 Tracey I, Woolf C,
Andrews N. Composite pain
biomarker signatures for
objective assessment and
effective treatment. Neuron
16 World Health Organization.
Classification of Diseases 11th
(accessed October 2019).
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International classification of
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18 Treede RD et al. Chronic pain
as a symptom or a disease: the
IASP Classification of Chronic
Pain for the International
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19 Nicholas M et al. The IASP
Taskforce for the Classification
of Chronic Pain. The IASP
classification of chronic pain for
ICD-11: chronic primary pain.
20 ICD-11. MG30.0 Chronic
primary pain. https://icd.
32835 (accessed October 2019).
21 Duenas M et al. A review of
chronic pain impact on patients,
their social environment and the
health care system. J Pain Res
22 Reid KJ et al. Epidemiology
of chronic non-cancer pain in
Europe: narrative review of the
prevalence, pain treatment and
pain impact. Curr Med Res Opin
23 Bassols A et al. How does
the general population treat
their pain? A survey in Catalonia.
J Pain Symptom Manage
24 Lopez-Silva M et al. Cavidol:
quality of life in pain and
primary care. Rev Soc Esp Dolor
25 Breivik H et al. OPENMinds.
The individual and societal
burden of chronic pain in
Europe: the case for strategic
prioritization and action to
improve knowledge and
availability of appropriate care.
BMC Public Health 2013;13:1229.
26 Watson PJ et al. Medically
certified work loss, recurrence
and costs of wage compensation
for back pain: a follow up study of
the working population of Jersey.
Br J Rheumatol 1998;37:82–6.
27 Blyth FM et al. Chronic pain
and frequent use of health care.
28 Keeley P et al. Psychosocial
predictors of health-related
quality of life and health service
utilization in people with
chronic low back pain. Pain
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